The clinical significance of osteoporosis is in the occurrence of fractures and re-fractures. The main risk factor of sustaining a fracture is a previous one, but a recent fracture is a better ...fracture risk factor than fracture history. The role of the recency of fracture has been shown for both vertebral and non-vertebral fracture risk. This imminent risk is explained by both bone-related factors (underlying osteoporosis) and fall-related factors (including those related to postfracture care). Such a short-term increased risk has been shown also in patients initiating corticosteroids and in frail osteoporotic subjects with central nervous system (CNS) diseases or drugs targeting CNS, and thus a high risk of falls. Patients with an imminent (i.e. 2 years) risk of fracture or refracture should be identified in priority in order to receive an immediate treatment and a program of fall prevention.
Inflammatory diseases and bone fragility Briot, K.; Geusens, P.; Em Bultink, I. ...
Osteoporosis international,
12/2017, Letnik:
28, Številka:
12
Journal Article
Recenzirano
Systemic osteoporosis and increased fracture rates have been described in chronic inflammatory diseases such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, inflammatory ...bowel diseases, and chronic obstructive pulmonary disease. Most of these patients receive glucocorticoids, which have their own deleterious effects on bone. However, the other main determinant of bone fragility is the inflammation itself, as shown by the interactions between the inflammatory mediators, the actors of the immune system, and the bone remodelling. The inflammatory disease activity is thus on top of the other well-known osteoporotic risk factors in these patients. Optimal control of inflammation is part of the prevention of osteoporosis, and potent anti-inflammatory drugs have positive effects on surrogate markers of bone fragility. More data are needed to assess the anti-fracture efficacy of a tight control of inflammation in patients with a chronic inflammatory disorder. This review aimed at presenting different clinical aspects of inflammatory diseases which illustrate the relationships between inflammation and bone fragility.
X-linked hypophosphatemia (XLH) is a rare genetic skeletal disease where increased phosphate wasting in the kidney leads to hypophosphatemia and prevents normal mineralization of bone and dentin. ...Here, we examined the periodontal status of 34 adults with XLH and separated them according to the treatment they received for hypophosphatemia. We observed that periodontitis frequency and severity were increased in adults with XLH and that the severity varied according to the hypophosphatemia treatment. Patients who benefited from an early and continuous vitamin D and phosphate supplementation during their childhood presented less periodontal attachment loss than patients with late or incomplete supplementation. Continued hypophosphatemia treatment during adulthood further improved the periodontal health. Extracted teeth from patients with late or incomplete supplementation showed a strong acellular cementum hypoplasia when compared with age-matched healthy controls. These results show that XLH disturbs not only bone and dentin formation but also cementum and that the constitutional defect of the attachment apparatus is associated with attachment loss.
Summary
Low serum total alkaline phosphatase level (ALP), the hallmark for hypophosphatasia (HPP), must be recognized to provide appropriate care of the patients and to avoid antiresorptive ...treatment. The prevalence of persistent low ALP in a clinical setting is 0.13 % and the recognition is very low (3 %).
Introduction
A low serum total alkaline phosphatase level is the hallmark for the diagnosis of hypophosphatasia. Although very rare, HPP must be recognized to provide appropriate treatment of non-union fractures and to avoid potentially harmful drugs, such as antiresorptive treatments. The aim of this study was to assess the recognition of persistent low ALP in a tertiary care hospital.
Methods
Between the 1st of January and the 31st of December 2013, 48,755 patients had ALP assessment in the Biochemistry Department of our hospital. Sixty-eight patients had all serum ALP values persistently below 40 IU/l. Among them, six had potential causes of secondary hypophosphatasia. We consulted the summary discharges of the 62 patients in order to check for the notation of low ALP. Patients from the departments of rheumatology and internal medicine were contacted to fulfill a questionnaire about clinical manifestations potentially related to HPP.
Results
0.13 % of hospitalized patients had persistently low value. They were 46.5 ± 17.7 years old, and 73 % were females. The low ALP value was notified in the discharge summary for two patients (3 %), without any comment. Twenty-four patients (46 + /-16 years old) were contacted. Eight patients had fractures; two had a diagnosis of rickets in the childhood; two had symptomatic chondrocalcinosis. Nine had dental abnormalities. Three were receiving a bisphosphonate; two of them had a fracture while being treated with bisphosphonate.
Conclusion
Our study shows that low ALP is not recognized in a clinical setting in adults hospitalized in a tertiary care hospital.
Bone lytic lesions are a possible complication of pseudohypoparathyroidism type 1B, in undertreated adult patients. Whole body 18F F-fluorocholine PET/CT is a useful imaging tool to assess brown ...tumor progression in this context. We describe the case of a 33-year-old woman, referred for the diagnostic evaluation of lytic bone lesions of the lower limbs, in the context of asymptomatic pseudohypoparathyroidism. She had been treated with alfacalcidol and calcium during her childhood. Treatment was discontinued at the age of 18 years old because of the lack of symptoms. A femur biopsy revealed a lesion rich in giant cells, without malignancy, consistent with a brown tumor. Laboratory tests showed a parathyroid level at 1387 pg/ml (14–50). Whole-body Fluorocholine PET/CT revealed hypermetabolism of bone lesions. The final diagnosis was brown tumors related to hyperparathyroidism complicating an untreated pseudohypoparathyroidism. Genetic testing confirmed PHP type 1B. Pseudohypoparathyroidism with radiographic evidence of hyperparathyroid bone disease, is a very rare condition due to parathyroid hormone resistance in target organs, i.e., kidney resistance, but with conserved bone cell sensitivity. It has been reported in only a few cases of pseudohypoparathyroidism type Ib. Long-term vitamin D treatment was required to correct bone hyperparathyroidism. With this rationale, the patient was treated with calcium, alfacalcidol, and cholecalciferol. One-year follow-up showed complete resolution of pain, improvement in serum calcium, and regression of bone lesions on 18FF-fluorocholine PET/CT. This case illustrates the usefulness of 18FF-fluorocholine PET/CT for the imaging of brown tumors in pseudohypoparathyroidism type 1B, and emphasizes the importance of calcium and vitamin D treatment in adult patients, to avoid the deleterious effects of high parathyroid hormone on skeletal integrity.
Summary
This study aims to compare the sagittal global spinal balance of patients consulting for osteoporosis, aged above 50 years with and without osteoporotic vertebral fractures (VFs). Global ...spinal balance is abnormal even in subjects without VFs. VFs and age are determinants of sagittal global balance; however, pelvic parameters play a role in compensatory mechanisms.
Introduction
This study aims to compare the spine curvatures, pelvic parameters, and the sagittal global spinal balance of patients aged above 50 years with and without osteoporotic vertebral fractures.
Methods
Two hundred patients (95 % women) aged 68.3 ± 9.5 years underwent full skeleton radiographs in the standing position, by EOS®, a low dose biplane X-ray imaging system. VFs were evaluated according to Genant’s classification. Spinal (thoracic and lumbar Cobb’s indices, thoracic and lumbar tilts) and pelvic (pelvic tilt, sacral slope, and pelvic incidence) parameters were measured. Sagittal spinal balance was measured using the C7 plumb line and the spinosacral angle (SSA). We compared these parameters in patients with and without vertebral fracture and assessed the determinants of abnormal sagittal spinal balance.
Results
Sixty-nine patients had at least one VF. The sagittal spinal balance was significantly altered in patients with at least one VF, and there was an effect of the number and severity of VFs on parameters. Discriminative value for identification of patients with at least one VF, assessed by Area Under the Curves (AUCs) was 0.652 and 0.706 for C7 plumbline and SSA, respectively. Using multivariate analysis, parameters significantly associated with abnormal spinal balance (SSA) were the presence of at least one VF (OR = 4.96,
P
< 0.0001), age (OR = 1.07,
P
= 0.0006), and high pelvic incidence as a protective factor (OR = 0.93,
P
< 0.0001).
Conclusions
Global spinal balance is abnormal in subjects consulting for osteoporosis, even in subjects without VFs. VFs and age are determinants of abnormal sagittal global balance; however, pelvic parameters play a role in compensatory mechanisms.
How long should we treat? Roux, C.; Briot, K.
Osteoporosis international,
06/2014, Letnik:
25, Številka:
6
Journal Article
Recenzirano
Osteoporosis is a chronic disease, for which effective drugs are available. These drugs have reduced the risk of osteoporosis-related fractures in robust trials of 3–5 years duration. There is no ...evidence of anti-fracture efficacy for treatments of longer duration. The consequences of stopping treatments are very different for the different molecules. Bisphosphonates can be safely discontinued after 3–5 years of treatment if there was optimal adherence and if patients are no longer osteoporotic. This discontinuation cannot be applied in patients with recent fractures or for other treatments. Safety of prolonged treatment is a huge concern which must be managed appropriately. The decision of a prolonged treatment is driven by the underlying risk of fracture. This risk must be assessed regularly in order to share with the patient the benefit-risk ratio of prolonged treatment.
Summary
We performed a study to identify potential causes and risk factors of vertebral fracture cascade. Vertebral fracture cascade is a severe clinical event in patients with bone fragility. Only ...half of patients have an identified cause of secondary osteoporosis.
Introduction
Vertebral fracture (VF) is the most common osteoporotic fracture, and a strong risk factor of subsequent VFs leading to VF cascade (VFC). We prompted a study to identify potential causes and risk factors of VFC.
Methods
VFC observations were collected retrospectively between January 2016 and April 2017. VFC was defined as an occurrence of at least three VFs within 1 year.
Results
We included in 10 centers a total of 113 patients with VFC (79.6% of women, median age 73, median number of VFs in the cascade, 5). We observed 40.5% and 30.9% of patients with previous major fractures and a previous VF, respectively, and 68.6% with densitometric osteoporosis; 18.9% of patients were currently receiving oral glucocorticoids and 37.1% in the past.
VFC was attributed by the physician to postmenopausal osteoporosis in 54% of patients. A secondary osteoporosis associated with the VFC was diagnosed in 52 patients: glucocorticoid-induced osteoporosis (25.7%), non-malignant hemopathies (6.2%), alcoholism (4.4%), use of aromatase inhibitors (3.6%), primary hyperparathyroidism (2.7%), hypercorticism (2.7%), anorexia nervosa (2.7%), and pregnancy and lactation-associated osteoporosis (1.8%). A total of 11.8% of cases were reported following a vertebroplasty procedure. A total of 31.5% patients previously received an anti-osteoporotic treatment. In six patients, VFC occurred early after discontinuation of an anti-osteoporotic treatment, in the year after the last dose effect was depleted: five after denosumab and one after odanacatib.
Conclusion
The results of this retrospective study showed that only half of VFC occurred in patients with a secondary cause of osteoporosis. Prospective studies are needed to further explore the determinants of this severe complication of osteoporosis.
Summary
The effect of lumbar osteoarthritis on bone density and trabecular bone score (TBS) was evaluated cross-sectionally and prospectively in postmenopausal women. Lumbar spine osteoarthritis was ...graded according to Kellgren and Lawrence grades. Lumbar osteoarthritis was found to increase lumbar spine bone density, but not TBS.
Introduction
Lumbar osteoarthritis overestimates lumbar bone density (areal bone mineral density (aBMD)). A new texture parameter, the TBS, has been proposed. Calculation of aBMD uses grey level value, while TBS uses grey level variation. Therefore, our hypothesis was that TBS is not influenced by lumbar spine osteoarthritis.
Methods
Menopausal women participating in osteoporosis and ultrasound (OPUS) study were included. They had an aBMD measurement of the spine and hip at baseline and 6-year visit. TBS was calculated on lumbar spine dual-energy X-ray absorptiometry (DXA) scans in an automated manner. The presence of lumbar osteoarthritis was evaluated on baseline radiographs using Kellgren and Lawrence (K&L) classification. Grades range from 0 to 4. In our study, osteoarthritis was defined by at least K&L grade 2.
Results
This study included 1,254 menopausal women (66.7 ± 7.1 years). Among them, 727 attended the 6-year follow-up visit. Patients with lumbar osteoarthritis had an aBMD higher than those without lumbar osteoarthritis at the lumbar spine, but not at the hip. However, the aBMD significantly increased in all sites with the grade of K&L. In contrast, spine TBS was not different between patients with and without lumbar osteoarthritis (
p
= 0.70), and it was not correlated with K&L grade. Spine TBS and aBMD at all sites were negatively correlated with age (
p
< 0.0001). Body mass index was correlated positively with aBMD and negatively with spine TBS (
p
< 0.0001). The 6-year change of aBMD was significant in the hip and nonsignificant in the lumbar spine. That of TBS was significant, with a 3.3 % decrease (
p
< 0.0001), independent of K&L grade (
p
= 0.28).
Conclusion
In postmenopausal women, lumbar osteoarthritis leads to an increase in lumbar spine aBMD. In contrast, spine TBS is not affected by lumbar osteoarthritis.
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